base hospital 4

CPAP Use in Severe Respiratory Distress

  • Indications for CPAP (Continuous Positive Airway Pressure):

    • Age: 18 years or older

    • Must be tachypneic (increased respiratory rate)

    • Must be normotensive (normal blood pressure)

    • SpO2 < 90% or using accessory muscles for breathing

Contraindications for CPAP

  • Asthma Exacerbation

  • Suspected Pneumothorax

  • Airway Issues: Unprotected/unstable airway

  • Major trauma or burns involving the head or torso

  • Presence of a tracheostomy

  • Inability to sit upright

  • Patient unable to cooperate

Considerations During CPAP

  • Consider administration of salbutamol or nitroglycerin (nitro) during CPAP use

  • Use MDI chamber to avoid breaking seal while administering salbutamol for COPD

  • The use of nitro should not interrupt CPAP if the patient is improving on CPAP

CPAP Settings

  • Initial pressure starting at 5 cmH2O

  • Titrate to 2.5 cmH2O, wait 5 minutes before further adjustments

  • Maximum pressure can be titrated to 15 cmH2O

  • Flow rate: 50-100% FiO2 (Fraction of inspired oxygen)

  • Make sure FiO2 stays less than 92% despite treatment

Cardiogenic Shock

  • Indicators: Must have hypotension and clear lung sounds

  • Fluid overload is a contraindication

  • Classification: Blood pressure must be greater than 90 mmHg

    • Generally, if BP < 100 mmHg, it's considered hypotensive

  • IV fluid bolus administration: 10 mL/kg instead of the standard 20 mL/kg for adults over 18 years

  • Maximum IV bolus capped at 1000 mL

Management of Traumatic Hemorrhage with TXA (Tranexamic Acid)

  • Description: TXA is used for excessive bleeding from physical injury, contributing to preventable deaths

  • Common Causes of Hemorrhage:

    • Motor vehicle collisions (MVCs)

    • Falls from heights

    • Penetrating injuries (gunshot/stab wounds)

    • Sports-related trauma

Indications for TXA

  • Perfused external bleeding evidenced by:

    • Rapid/weak pulse

    • Hypotension

    • Cool, clammy skin

    • Altered mental status

  • Symptoms of impending shock due to failed compensatory mechanisms

Hemodynamic Instability

  • Defined as either:

    • Hypotension or blood pressure < 90 mmHg

    • Heart rate > 110 beats per minute

Trauma Triad of Death

  • Complication arising from hemorrhage includes three factors:

    • Hypothermia

    • Acidosis

    • Coagulopathy

  • Prompt recognition and management of these factors is essential to prevent mortality

Management Techniques for Hemorrhage

  • External bleeding control using:

    • Direct pressure

    • Hemostatic dressings

    • Tourniquets for extremity bleeding

  • Internal bleeding challenges:

    • Rapid transport

    • Pelvic binder for stabilizing fracture sites

    • TXA administration when indicated

Contraindications for TXA

  • Allergy or known sensitivity to TXA

  • Greater than 3 hours from time of injury

  • Isolated head injuries

TXA Administration Guidelines

  • Dosage: 1000 mg in 10 mL IV

  • Key pharmacokinetics:

    • Onset: Immediate effect within 10-15 minutes

    • Peak Effect: 1 to 1.5 hours

    • Duration: Approx. 11 hours

    • Half-life: 2 hours

    • Metabolized by renal system

Side Effects of TXA

  • Abdominal pain, nausea and vomiting, headache

  • Musculoskeletal pain, seizures

  • Possible anaphylaxis and transient hypotension when infusing quickly

Use of TXA in Trauma

  • Effective for traumatic internal or uncontrolled external bleeds from:

    • Neck

    • Axilla

    • Groin area

  • Not indicated for isolated extremity fractures or non-traumatic bleeding

Supraventricular Tachycardia (SVT) Management

  • Definitions: Narrow QRS complexes and rapid heart rates, usually exceeding 150 bpm

  • Symptoms of SVT: Palpitations, chest pain, impending doom, and dyspnea

  • Recognize rhythms and differentiate between tachycardias

Modified Valsalva Maneuver for SVT

  • Indications:

    • Patients 18 years or older

    • Heart rate > 150 bpm with narrow complex

  • Contraindications:

    • Unstable patients, history of certain arrhythmias (e.g., A-fib)

Valsalva Procedure

  • Sit patient in semi-seated position

  • The patient must blow into a 10 mL syringe for 15 seconds

  • Lay them back and elevate their legs for 15 seconds

  • It can be done twice; if unsuccessful, consider further intervention with adenosine

  • Success rate: 43% for relieving SVT

Special Populations in SVT Management

  • Pregnant patients have a low risk of initiating labor and cannot be discharged upon resolution

  • Patients with chest pain or acute conditions must be managed accordingly

IV Cannulation and Fluid Administration

  • Guidelines for IV fluid boluses for specific populations

  • Under 2 years: 20 mL/kg fluid bolus

  • Over 2 years: 10 mL/kg fluid bolus

  • Reassess every 100 mL for younger patients and every 250 mL for older populations

Criteria for Treat and Discharge Post-Seizure

  • Specific criteria include:

    • Age 18-65 with a documented history of epilepsy

    • Single seizure episode within the last 24 hours

    • Compliance with anticonvulsant medications

    • No injury during the seizure episode

    • Vitals stable and no associated conditions like fever or pregnancy

Patellar Dislocation Reduction Procedure

  • For lateral dislocation, patient to be aged 10-50 years with no high-velocity trauma

  • If dislocation occurs due to mild physical activity, proceed with reduction attempts

  • Maximum attempts: Two; if unsuccessful, transport in a comfortable position

Final Recommendations Before Practical Testing

  • Familiarize yourself with the directives and patient scenarios

  • Utilize the existing resources (such as the directive book) effectively without solely relying upon them

  • Understand the mechanisms and vital signs as they relate to treatment protocols

  • Prior knowledge and communication during testing are crucial for a successful appraisal.